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Review Articles

The Role of Debriefing in Simulation-Based Learning

Ruth M. Fanning, Mb, MRCPI,FFARCSI;

and David M. Gaba, MD

The aim of this paper is to critically review what is felt to beimportant about the role of debriefing in the field of simula-tion-based learning, how it has come about and developedover time, and the different styles or approaches that are usedand how effective the process is. A recent systematic review ofhigh fidelity simulation literature identified feedback (in-cluding debriefing) as the most important feature of simula-tion-based medical education.1 Despite this, there are sur-prisingly few papers in the peer-reviewed literature toillustrate how to debrief, how to teach or learn to debrief,what methods of debriefing exist and how effective they are atachieving learning objectives and goals.

This review is by no means a systematic review of all theliterature available on debriefing, and contains informationfrom both peer and nonpeer reviewed sources such as meet-ing abstracts and presentations from within the medical fieldand other disciplines versed in the practice of debriefing suchas military, psychology, and business. It also contains manyexamples of what expert facilitators have learned over years ofpractice in the area. We feel this would be of interest to nov-ices in the field as an introduction to debriefing, and to ex-perts to illustrate the gaps that currently exist, which might beaddressed in further research within the medical simulationcommunity and in collaborative ventures between other dis-ciplines experienced in the art of debriefing.

THE BACKGROUND OF SIMULATION-BASEDLEARNING

Generally, in simulation-based learning, we are dealingwith educating the adult professional. Adult learning pro-vides many challenges not seen in the typical student popu-lation. Adults arrive complete with a set of previous life ex-periences and frames (“knowledge assumptions, feelings”),ingrained personality traits, and relationship patterns, whichdrive their actions.2 Adult learners become more self-di-rected as they mature. They like their learning to be problemcentered and meaningful to their life situation, and learn best

when they can immediately apply what they have learned.3

Their attitudes towards any specific learning opportunity willvary and depend on factors such as their motivation for at-tending training, on whether it is voluntary or mandatory,and whether participation is linked directly to recertificationor job retention. Traditional teaching methods based on lin-ear communication models (ie, a teacher imparts facts to thestudent in a unidirectional manner) are not particularly ef-fective in adult learning, and may be even less so in team-oriented training exercises. The estimated half-life of profes-sional knowledge gained through such formal education maybe as little as 2 to 2.5 years.4 In the case of activities requiringboth formal knowledge and a core set of skills, such as Ad-vanced Cardiac Life Support, retention can be as little as 6 to12 months.5,6

Much of the research in teaching adults indicates thatactive “participation” is an important factor in increasing theeffectiveness of learning in this population.7 In fact, in anygiven curriculum, learning occurs not only by the formalcurriculum per se but informally through personalizedteaching methods (informal curricula), and even more sothrough embedded cultures and structures within the orga-nization (hidden curricula).8

Adults learn best when they are actively engaged in theprocess, participate, play a role, and experience not only con-crete events in a cognitive fashion, but also transactionalevents in an emotional fashion. The learner must make senseof the events experienced in terms of their own world. Thecombination of actively experiencing something, particularlyif it is accompanied by intense emotions, may result in long-lasting learning. This type of learning is best described asexperiential learning: learning by doing, thinking about, andassimilation of lessons learned into everyday behaviors. Kolbdescribes the experiential learning cycle as containing fourrelated parts: concrete experience, reflective observation, ab-stract conceptualization, and active experimentation.9 Gibbsalso describes four phases: planning for action, carrying outaction, reflection on action, and relating what happens backto theory.10 Grant and Marsden similarly describe the expe-riential learning process as having an experience, thinkingabout the experience, identifying learning needs that wouldimprove future practice in the area, planning what learning toundertake, and applying the new learning in practice.11

Simulation training sessions, which are structured withspecific learning objectives in mind, offer the opportunity to

From the Department of Anesthesia, Stanford University, Stanford, CA.

The authors have indicated they have no conflict of interest to disclose.Reprints: Ruth M. Fanning, Department of Anesthesia, StanfordUniversity Medical School, 300 Pasteur Drive, Stanford, CA 90314 (e-mail:ruthfanning@ireland.com).

Copyright © 2007 Society for Simulation in HealthcareDOI: 10.1097/SIH.0b013e3180315539

Vol. 2, No. 2, Summer 2007 115

go through the stages of the experiential cycle in a structuredmanner and often combine the active experiential compo-nent of the simulation exercise itself with a subsequent anal-ysis of, and reflection on the experience, aiming to facilitateincorporation of changes in practice. Simulation offers theopportunity of practiced experience in a controlled fashion,which can be reflected on at leisure. Experiential learning isparticularly suited to professional learning, where integrationof theory and practice is pertinent and ongoing.11 In experi-ential learning, the experience is used as the major source oflearning but it is not the only one. Both thinking and doingare required and must be related in the minds of the learner.10

The concept of reflection on an event or activity and sub-sequent analysis is the cornerstone of the experiential learn-ing experience. Facilitators guide this reflective process. In-deed this ability to reflect, appraise, and reappraise isconsidered a cornerstone of lifelong learning. This is one ofthe core elements of training in healthcare articulated by theAccreditation Council on Graduate Medical Education in theUnited States.12 In practice however, not everyone is natu-rally capable of analyzing, making sense, and assimilatinglearning experiences on their own, particularly those in-cluded in highly dynamic team-based activities. The attemptto bridge this natural gap between experiencing an event andmaking sense of it led to the evolution of the concept of the“postexperience analysis”13 or debriefing. As such, debriefingrepresents facilitated or guided reflection in the cycle of ex-periential learning.

ORIGINS OF DEBRIEFING INSIMULATION-BASED LEARNING

Historically, debriefing originated in the military, inwhich the term was used to describe the account individualsgave on returning from a mission.14 This account was subse-quently analyzed and used to strategize for other missions orexercises. This military-style debriefing was both educationaland operational in its objectives. Another connotation of de-briefing developed out of the combat arena as a therapeuticor psychological association, as sort of “defusing,” and aidedthe processing of a traumatic event with the aim of reducingpsychologic damage and returning combatants to the front-line as quickly as possible. In this therapeutic approach, em-phasis was placed on the importance of the narrative to re-construct what happened. This cognitive reconstruction ofevents was performed in groups so that there was a sharedmeaning. The participants were brought together to describewhat had occurred, to account for the actions that had takenplace, and to develop new strategies with each other and thecommanding officers.

Another form of debriefing, critical incident debriefing,was pioneered by Mitchell15 and is used to mitigate stressamong emergency first responders. He formulated a set ofprocedures termed the Critical Incident Stress Debriefing(CISD).15 CISD is a facilitator-led approach to enable partic-ipants to review the facts, thoughts, impressions, and reac-tions after a critical incident. Its main aim is to reduce stressand accelerate normal recovery after a traumatic event bystimulating group cohesion and empathy.

Dyregrov modified this technique and called it psycholog-ical debriefing, designed to take place in the 48 to 72 hoursafter a traumatizing event in an attempt to assist participantsin the cognitive and emotional processing of what they expe-rienced.16

Currently, there is concern that an unrealistic expectationof CISD and its usefulness may be developing. A single ses-sion approach may be inadequate for certain individuals andsituations, particularly as the technique is applied outside therealms for which it was originally designed.17

Another origin for the term “debriefing” comes from ex-perimental psychology, and describes the means by whichparticipants who have been deceived in some manner as partof a psychology study are informed of the true nature of theexperiment.18 The purpose of this ethically required debrief isto allow dehoaxing to occur, and to reverse any negativeeffects the experience may have had.19

Each of the three fields have contributed to the develop-ment of debriefing in the educational arena, facilitator-ledparticipant discussion of events, reflection, and assimilation ofactivities into their cognitions produce long-lasting learning.

THE DEBRIEFING PROCESSApproach to Debriefing

Just as in noneducational debriefing, where there exists anethical duty of facilitators to set a safe, confidential scene forfacilitation, there is the ethical obligation for the facilitator insimulation-based learning to determine the parameterswithin which behavior will be analyzed, thereby attemptingto protect participants from experiences that might seriouslydamage their sense of self-worth.20 To ensure a successfuldebriefing process and learning experience, the facilitatormust provide a “supportive climate”21 where students feelvalued, respected, and free to learn in a dignified environ-ment. Participants need to be able to “share their experiencesin a frank, open and honest manner.”14 An awareness of thevulnerability of the participant is needed, which must be re-spected at all times. This is highlighted by a recent studyregarding the barriers to simulation-based learning, whereapproximately half the participants found it a stressful andintimidating environment and a similar proportion cited afear of the educator and their peers’ judgment.22

It is essential that the facilitator creates an environment oftrust early on, typically in the prebrief session. This prebriefperiod is a time when the facilitator illustrates the purpose ofthe simulation, the learning objectives, the process of debrief-ing, and what it entails. It is the period where the participantslearn what is expected of them and sets the ground rules fortheir simulation-based learning experience. It is also a timefor the facilitator to reflect on the learning objectives, and toconsider that every participant comes to the simulation witha preceding set of individual frames and life experiences.2

These previous experiences have an impact on how effectivetraining will be, and need to be taken into considerationirrespective of the debriefing model employed. These framesor internal images of reality, how a person perceives some-thing relative to someone else, affect the way people receive,process, and assimilate information.2 The simulation sce-

116 Fanning et al. Simulation in Healthcare

nario and the debriefing techniques employed need to takeindividual learning styles into consideration.

This factor is illustrated by Kolb with the incorporation ofthe experiential learning cycle with basic learning styles.23

Four prevalent learning styles are identified: diverging, assim-ilating, converging, and accommodating. Participants with di-verging learning styles use concrete experience and reflectiveobservation to learn. This style facilitates generation of ideas,such as brainstorming. Individuals with this learning styleprefer to work in groups, listening and receiving feedback.Individuals with assimilating learning styles prefer abstractconceptualization and reflective observation. They like read-ing, lectures, and analysis. Converging-styled learners use ab-stract conceptualization and active experimentation. Theylike to find practical uses for ideas and theories. In a formallearning setting, they prefer to experiment with new ideas,simulations, laboratory experiments, and practical applica-tions. Accommodating-styled learners use concrete experi-ence and active experimentation. People with this style learnprimarily from hands-on experience. In formal learning, theyprefer to work in teams, to set goals, to do fieldwork, and totest different approaches to compiling a project. When learn-ing in teams, individuals tend to orientate themselves andcontribute to the team learning process by using their indi-vidual learning styles to help the team achieve its learningobjectives.

Highly effective teams tend to possess individuals with anumber of different learning styles. In our experience, pair-ing appropriately learning-styled individuals may add to theteam’s performance. Individual learning styles and teamcomposition are important factors for facilitators to considerwhen choosing which style of debriefing will be most success-ful for each simulation session. It is also important for facil-itators to learn about the characteristics of the group: whethergroup members know each other, are novices or are experi-enced, or are new to simulation. The prebrief period canafford the experienced facilitator an opportunity to observeteam behaviors and identify learner characteristics early on,and debrief accordingly.

Structural Elements of the Debriefing ProcessDespite many approaches to debriefing,24,25 there are a

number of structural elements common to most forms offacilitation. Lederman identified seven common structuralelements involved in the debriefing process (Table 1).18 Thefirst two elements are the debriefer(s) and those to be debriefed.It is possible for these two to be the same if participants act astheir own debriefers.26 The third element is the experience

itself (eg, the simulation), and the fourth is the impact thisexperience has on the participants. The concept of impact isimportant because adult learners typically need to be emo-tionally moved by the event, and the event needs to be rele-vant to their everyday lives to make an impact. The fifth andsixth elements involve recollection and report. Reporting ofthe event, although usually carried out in a verbal manner,may be written or involve the completion of a formal ques-tionnaire.24 The seventh element is time: the experience willbe seen differently depending on how much time has passedbefore the debriefing. Although most debriefing approachesare conducted very soon after the experience, some allowmore time for formal reflection, with reporting long after theevent via a written report of an individual event or throughkeeping a journal (a written review of educational experi-ences over a semester).24

Models of DebriefingA number of models exist incorporating these structural

elements and describe various debriefing or facilitationstyles.27–29 These models probably all evolve out of the natu-ral order of human processing: to experience an event, toreflect on it, to discuss it with others, and learn and modifybehaviors based on the experience. Although reflection aftera learning experience might occur naturally, it is likely to beunsystematic. It may not occur at all especially if the pressureof events prevents focusing on what has just transpired. Con-ducting a formal debriefing focuses the reflective process,both for individual participants and for the group as a whole.

Naturally, debriefings may move of their own powerthrough three phases: description, analogy/analysis, and ap-plication. However, without a facilitator participants mayhave trouble moving out of this first descriptive phase, par-ticularly the active “hot-seat” participant who is emotionallyabsorbed in the event and is blinkered in their view of whathas occurred. The challenge for the facilitator is to allowenough time for defusing to occur, but direct the discussionin a more objective, broad-based capacity. The facilitatorneeds to move the discussion away from the very personal-ized account of what the participant thought occurred, to themore global perspective, away from the individual to thegroup, and the person to the event, but must be cognizant notto cut the participant off, or make him/her feel alienated.

Although the core of the debrief centers on reflection ofthe active experience and making sense of the event, there aresupporting phases that are necessary to allow this reflectionand assimilation to occur. These phases of the debrief aredescribed by many authors, and are categorized in differentmanners. The basic tenets of the various debriefing modelshave many overlapping elements (Table 2).

An initial phase of identifying the impact of the experi-ence, considering the processes that developed and clarifyingthe facts, concepts, and principles which were used in simu-lation is described by Thatcher and Robinson.27 Ledermandescribes this phase as the introduction to systematic reflec-tion and analysis that follows the active component of thesimulation: “the recollection of what happened and descrip-tion of what participants did in their own words.”28 Paternek

Table 1. Seven Common Structural Elements Involved in theDebriefing Process18

1. Debriefer

2. Participants to debrief

3. An experience (simulation scenario)

4. The impact of the experience (simulation scenario)

5. Recollection

6. Report

7. Time

Vol. 2, No. 2, Summer 2007 © 2007 Society for Simulation in Healthcare 117

describes this introductory phase as the description of theevents that occurred.29

The second phase is described as identifying the ways inwhich emotion was involved, either individually or for thegroup;27 the intensification and personalization of the analy-sis of the experience, where participants explore the feelingsthey experienced during the event;28 or the emotional andempathic content of the discussion.29

The third phase involves identifying the different viewsformed by each participant, and how they correlate with thepicture as a whole;27 the generalization and application of theexperience, during which participants attempt to make com-parisons with real-life events;28 a phase of explanations andanalysis, everyday applicability and evaluation of behaviors.2

Objectives of the Debriefing SessionThe design of the debriefing session should be tailored to

the learning objectives and the participant and team charac-teristics. Objectives may be well defined, and specified be-forehand, or may be emergent and evolve within the simula-tion. For well-defined objectives, such as a technical skill or aparticular team behavior, the debriefing session affords theopportunity to examine how closely participants’ perfor-mance has approached a known target, and what needs to bedone to bridge any observed gaps between performance andtarget. It also affords an opportunity to share these objectiveswith participants. With emergent objectives, participantsmay be asked to reflect on the observed evolution of thescenario and to see how the behaviors, attitudes, and choicesuncovered in the simulation relate to real life situations.When exploring objectives or goals, there are two main ques-tions: 1) which pieces of knowledge, skills, or attitudes are tobe learned? and 2) what specifically should be learned about

each of them? In the case of emergent objectives, simulationsmay be viewed as experiments in which participants try alter-native ways of behavior or test new strategies or courses ofaction. To debrief about such objectives is complicated be-cause there are fewer predefined ideas about how the partic-ipants should have acted, so discussion must focus aroundissues that arise from the events themselves and their mean-ing to those involved.

Role of the Facilitator in the Debriefing ProcessThere is a tension between making participants active and

responsible for their own learning versus ensuring they ad-dress important issues and extract maximum learning duringdebriefings. Data from surveys of participants indicates thatthe perceived skills of the debriefer have the highest indepen-dent correlation to the perceived overall quality of the simu-lation experience.30 As the skill of the debriefer is paramountin ensuring the best possible learning experience, training infacilitation is vital. A number of centers offer facilitationcourses providing training in debriefing skills (Table 3).31 Inaddition to the formal education of facilitators, techniquessuch as the pairing of expert with novice facilitators early intheir career to give guidance and direction are important. Arecent study of facilitation in problem-based learning illus-trated that while facilitators felt that a formal training courseprovided sufficient skills to commence debriefing, it was onlywith experience, and in the presence of an expert role modelthat they became more comfortable with the process.32 In thesame study, students commented on the skill of facilitators asbeing an important factor in the learning process and thecredibility of the course. Basic and advanced courses andrefresher courses in facilitation are probably universally re-quired.

The exact level of facilitation and the degree to which thefacilitator is involved in the debriefing process can depend ona variety of generic factors:

• The objective of the experiential exercise,• The complexity of the scenarios,• The experience level of the participants as individuals or

a team,• The familiarity of the participants with the simulation

environment,• Time available for session,• The role of simulations in the overall curriculum,• Individual personalities and relationships, if any, be-

tween the participants.Unlike the traditional classroom “teacher,” facilitators

tend to position themselves not as authorities or experts, butrather as colearners. This more fraternal approach may bemost productive where the learning objective is behavioralchange. Facilitators aim to guide and direct rather than tolecture. The role of the student or participant in debriefing isexpanded from the traditional passive role to one where theskills demanded of them are the ability to critically analyzeone’s own performance retrospectively—not just what wentwell but what went wrong, and why it went that way, and tocontribute actively to the learning process.

Table 2. Models of the Debriefing Process

Model

Thatcher and Robinson27

1. Identifying the impact of the experience

2. Identifying and considering the processes which developed

3. Clarifying the facts, concepts, and principles

4. Identifying the ways in which emotion was involved

5. Identifying the different views which each of the participantsformed

Lederman28

1. The introduction to the systematic reflection and analysis

2. The intensification and personalization of the analysis of theexperience

3. The generalization and application of the experience

Petranek29

1. Events

2. Emotions

3. Empathy

4. Explanations and analysis

5. Everyday applicability

6. Employment of information

7. Evaluation

118 Fanning et al. Simulation in Healthcare

Practical Points on DebriefingThere are a number of methods of debriefing, and levels of

facilitation that may be employed. Dismukes and Smith,while discussing debriefing in aviation, delineate three levelsof facilitation.33

HighParticipants largely debrief themselves with the facilitator

outlining the debriefing process and assisting by gently guid-ing the discussion only when necessary, and acting as a re-source to ensure that objectives are met. Thus, paradoxicallythe high level facilitation actually implies a low level of in-volvement by the facilitator. This level of facilitation—ini-tially described by Carl Rogers— describes the facilitator as acatalyst, allowing clients or students to draw their own con-clusions, creating their own prescription for change.34 Hedescribed “core conditions” for the facilitative process, bothcounseling and educational. These are congruence (realness),acceptance, and empathy. Realness refers to genuine nature

of the facilitator. The idea of acceptance is that the learnerfeels that their opinions are prized, as are their feelings andtheir person. For the third, empathy, the teacher aims tounderstand the learner’s viewpoint and have sensitivity for it.

Examples of techniques in high-level facilitation would bethe use of pauses to allow thoughtful responses and com-ment, open-ended questions and phrases rather than state-ments of fact. The artful use of silence is another technique todraw further discussion from the group.

IntermediateAn increased level of instructor involvement may be use-

ful when the individual or team requires help to analyze theexperience at a deep level, but are capable of much indepen-dent discussion. Examples of techniques used in intermedi-ate-level facilitation would include rewording or rephrasingrather than giving answers, asking questions in a number ofways to a number of participants and changing the tone ofquestions. Other techniques would be asking one member to

Table 3. List of Institutions and Organizations that Offer Formal Training for the Simulation-based Healthcare Educator31

Institution/Organization Course/Type of Training

Center for Advanced Medical Simulation Karolinksa University Hospital(http://www.simulatorcentrum.se/)

Several courses for faculty training on crisisresource management in anesthesia andemergency medicine.

Center for Medical Simulation, Boston (http://www.harvardmedsim.org/cms/) A variety of courses including week-long immersiveexperience for those who want to develop andmaintain healthcare simulation programs. Othercourses offer training for instructors who teachwith simulators, those who have leadershippositions.

Hertfordshire Intensive Care and Emergency Simulation Centre, University ofHertfordshire (http://www.health.berts.ac.uk.hicese/)

One-day course for participants to learn how totrain and teach with simulators and courses onmultidisciplinary simulation-based training.

Mainz simulation Center (http://www.simulationzentrum-mainz.de) Several “train the trainer” courses coveringsimulator operations and programming, crisisresource management, teamwork,communication skills, and debriefing techniques.

Mayo multidisciplinary simulation center (http://www.mayo.edu/simulationcenter/) Courses for participants to develop knowledge andskills in planning, designing, building andmaintaining a simulation center.

SIMS Medical Academy (http://www.healthprograms.org) Beginner and intermediate level courses forparticipants to learn how to develop andimplement patient simulation scenarios into theirlocal curriculum.

Society for Education in Anesthesia (http://www.asahq.org/) A variety of courses and workshops on developingteaching skills including the use of innovativesimulation technologies.

Simulation Center at the VA Palo Alto HCS, Stanford(http://www.med.stanford.edu/VA simulator/)

Faculty development courses on anesthesia andemergency medicine crisis resource management.

TuPass Center for Patient Safety and Simulation (http:/www.tupass.com) Several courses for instructors aimed at thecompetencies necessary to conduct simulationbased training in acute medical care crisis.

University of Miami Michael S. Gordon Center for Research in MedicalEducation (http://www.crme.med.miami.edu)

Several “training the trainer” courses forparticipants to learn to use a variety of simulationtools for a wide range of courses (acute stroke,disaster and terrorism response).

University of Pittsburgh WISER (http://www.wiser.pitt.edu/) A variety of courses covering the foundations forsimulation in healthcare, including simulatorprogramming, creating and developing asimulation center as well as faculty facilitator andtechnical support specialist preceptor training.

This list covers a number of well-known programs, but is not exhaustive. No endorsement of the programs by the Society of Simulation in Healthcare is implied.

Vol. 2, No. 2, Summer 2007 © 2007 Society for Simulation in Healthcare 119

comment on another, or moving around a group asking forinput from all team members.

LowAn intensive level of instructor involvement may be nec-

essary where teams show little initiative or respond only su-perficially. In such cases the facilitator guides the individualor the group through the debriefing stages, asks many ques-tions and strongly directs the nature of the discussion. Inlow-level facilitation, participants show little initiative andtend to respond only superficially. Here the facilitator mayneed to be directive to operate a stepwise or pattern of anal-ysis. Examples of techniques used in low-level facilitationwould include answering for participants, confirming state-ments, agreeing, recapping, and reinforcing thoughts andideas. Other techniques such as active listening, echoing, andexpanding on statements and nonverbal encouragementsuch as nodding, leaning forward, and focused eye contactare useful.

It is probably most beneficial to facilitate at the highestpossible level, with the participants independently generatinga rich discussion among themselves of all key issues. In ourexperience in healthcare, this ideal is rarely achieved, espe-cially with relatively junior trainees or with first-time simu-lation participants of any age. Matching the level of instructorinvolvement to the nature of the material and the group iscritical.

Conversely, there may be a tendency for instructors todebrief at a lower level (with more instructor involvement)than the participant group might really need—that is, to“overinstruct.” To ensure that participants become involvedat the highest level, a good prebrief is essential. Individualsand teams unfamiliar with this kind of learning may start offa sequence of simulations and debriefings with a need forhigh instructor input but then become more participant-directed as the day progresses.

Other Styles of FacilitationJust as different levels of facilitation may be employed to

suit the needs of participants, different facilitator techniquesmay be used to engage participants in the debriefing process.Examples of other styles of facilitation include: funneling,where the facilitator guides or funnels the participants, butrefrains from commenting; framing, introducing the experi-ence in a manner that enhances its relevance and meaning;and frontloading, using punctuated questions before or dur-ing an experience to redirect reflection. Solution-focused fa-cilitation changes the focus of questions away from problems,and directional-style debriefing is intended to change the waypeople feel or think.35

Techniques such as plus-delta may also be useful. Thistechnique which involves creating two headings or columnsentitled delta, the Greek symbol for change, and plus. Underthe delta column, the participants or/and the facilitator placeall the behaviors/actions they would change or improve on infuture, where the plus column contains examples of goodbehaviors or actions. Different participants can contribute tothe critique, which may single out individual or team behav-iors. Variations on the technique include placing behaviorsor actions that were found to be difficult on the delta column,

and easier tasks or behaviors on the plus column, and subse-quently discussing why this was the case.

Facilitators at the Karolinska University Hospital in Swedenuse a target-focused technique to aid facilitation.36 Target be-haviors are identified prior to the simulation scenario in theprebrief period, and subsequently during the debrief these canbe identified and evaluated by facilitators, participants, and byobservers. This technique offers a structure for debriefing thatmay facilitate debriefing by participants.

Facilitators may decide to use different communicationstyles while debriefing: using commands, cues, or questions.They may also decide to use acceptance and praise or bescolding and corrective.37 If there are a number of debriefers,they may decide to use opposing styles: “good cop-bad cop”to encourage discussion and cohesiveness within a partici-pant team. A group of debriefers may offer advantages wherespecific educational or technical points need to be addressed.An expert (expert content debriefer) may debrief on special-ized issues and offer credibility to the discussion, particularlywhere dealing with an experienced group of participants.When a number of facilitators are present, their roles need toclearly described before debriefing commences to avoid ex-cessive facilitator input in discussions. This is particularlypertinent if the principal debriefer is attempting to use tech-niques such as active listening and silence to encourage groupparticipation.

The Debriefing SettingThe physical environment in which debriefing is con-

ducted is also an important factor. For complex debriefingslasting more than a few minutes, debriefings often take placein a room separate from the active portion of the simulationto allow diffusion of tension and to provide a setting condu-cive to reflection (this also frees up the simulation room to beset up for the next scenario). However, not all debriefings areheld after the simulation, but in certain instances, for exam-ple, where the aim is to teach a technical skill or if the teambehaviors are seriously flawed, debriefing may occur duringthe simulation, “in-scenario” debriefing.

The debriefing room should be comfortable, private, anda relatively intimate environment (for example, a large audi-torium would typically not be appropriate). The seating ar-rangement may vary with the style of the debriefing and thedegree of facilitation intended. In a more traditional teachingapproach, the facilitator may position himself at the head ofthe table, whereas in a more participant-directed debrief, thefacilitator may be seated among the participants, away fromthe table, out of sight, or indeed even outside the debriefingroom. If a larger group is to be debriefed, participants may beseparated into smaller groups. Each subgroup might have anindividual facilitator, or they might self-debrief initially, andthen come together to express their thoughts in a larger groupsetting.

Steinwachs describes a way of debriefing a larger group,involving the “fish bowl” method.25 Here a smaller circleexists within a larger circle, and participants may move to theinner circle when they wish to actively participate in the de-brief. Steinwachs advises that individuals sit next to eachother to avoid creating “energy gaps” (opportunities for dis-

120 Fanning et al. Simulation in Healthcare

continuity in discussion as one participant is removed fromthe group as a whole). Irrespective of the type of facilitationmodels and communication styles used and the physical en-vironment debriefing is carried out in, it is always importantto be cognizant of the participants’ profiles (eg, novice/ex-pert) in delivering the debrief.

To Debrief or Not?Although many learning experiences require feedback,

debriefing is a special kind of feedback process. If the coreobjectives are to, for example, teach a technical skill such asintubation or central line placement, does the participantrequire in-depth facilitation and reflection on the skill tomaster it? We suggest that the learning objectives, target pop-ulation, and modalities of simulation will drive whether adebriefing is useful, and if so how in-depth the debriefingprocess needs to be. Typically topics that may benefit fromdebriefing are team training, crew resource managementskills and multidisciplinary training. Thiagarajan examinesthis concept of the necessity of the debrief by asking: 1) doparticipants lack a sense of closure and 2) can we derive usefulinsights through a discussion of the experience?38 If so, de-briefing should add to the experience.

The Effectiveness of Debriefing SessionsAlthough the experience in other high-hazard industries

that conduct complex simulations suggests that debriefing isimportant,39 what data exist regarding the actual benefits ofdebriefing? Such questions prompted a survey of debriefingpractices in 14 European Simulation Centers to explore whatexperienced debriefers instinctively felt were important ele-ments of a good debrief, and also what was felt to constitute apoor or harmful debrief.40 The survey was carried out inresponse to interest in the topic displayed at a workshop indebriefing at an international simulation education meeting.All respondents claimed that debriefing was the most impor-tant part of realistic simulator training, “crucial to the learn-ing process,” and if performed poorly could harm the trainee.The majority felt that a thorough prebrief was essential andstressed the importance of confidentiality and creating a non-threatening atmosphere. Elements of a good debrief includedthe use of open-ended questions, positive reinforcement, theuse of cognitive aids, and good use of audiovisual capabilities.Respondents felt that, where possible, facilitation or self-de-briefing should be encouraged. Elements of a poor debriefincluded the use of closed questions, criticism, or ridicule;concentrating on errors; or concentrating too much on thetechnical points and not enough on crew resource manage-ment skills. This survey’s findings reinforce common beliefsof experienced facilitators regarding good debriefing.

Intuitively, many instructors feel that such core elementsof debriefing are essential but what, if any, empirical dataexists to explore the real value of the debrief and the variousmethods of facilitation? How does one even approach assess-ing debriefing techniques? Lederman outlined a conceptualprocess for assessing the effectiveness of the debriefing pro-cess, which may serve as a template for future studies.18 Sheasks five questions:

1. Were the learning objectives met or enhanced throughthe debriefing?

2. How was the debriefing conducted considering situa-tional constraints (eg, time, finances, and group struc-ture)?

3. Was the correct strategy used to accomplish the learn-ing objectives given the situational constraints?

4. How uniformly, if at all, was the stated debriefing strat-egy actually implemented in practice?

5. What, if any, quality management of the debriefingprocess took place?

These questions can be raised about specific issues andtypes of debriefing. There are also some more general ques-tions about debriefing:

1. Do all types of simulations need a debrief, and if somedo, what benefits have been demonstrated?

2. Is self-debriefing or written debriefing sufficient or is afacilitator really needed?

3. How much, if at all, does playback of simulation videohelp the debriefing process?

4. Do specific methods of debriefing have specific bene-fits, or are they all alike?

A number of studies have found the debriefing processbeneficial. In a study aiming at improving dynamic decisionmaking and task performance involving computer simula-tion-based interactive learning environments, Qudrat-Ullahevaluated the usefulness of the debrief.41 The study assessedparticipants’ skills in a managing a dynamic task, such asplaying the role of fishing fleet managers in an environmentof over exploitation and mismanagement of renewable re-sources. Thirty-nine participants were examined over fourparameters: task performance, structural knowledge, heuris-tics knowledge, and cognitive effort. The experimental groupreceived a debrief, whereas the control group did not. Acrossall four domains the group who were debriefed did better.Similarly in a medical simulation study, Savoldelli et al. foundthat participant’s nontechnical skills failed to improve if theywere not debriefed.42

As Dismukes et al. state: “When it comes to reflecting oncomplex decisions and behaviors of professionals, completewith confrontation of ego, professional identity, judgment,motion, and culture, there will be no substitute for skilledhuman beings facilitating an in-depth conversation by theirequally human peers.”43

How Should We Debrief? Self-debriefing Versus Written/BlogDebriefing Versus Facilitated Debriefing

Increasingly, due to the cost of expert debriefers, there hasbeen an interest in self-debriefing.44 In fact, in a survey ofteam versus instructor-led debriefs, pilots surveyed wereequally satisfied with both methods.26 A recent healthcarestudy looked at the ability of participants to critique theirown performance and that of their colleagues, and how thatcritique was received.45 Subjects were asked to provide rat-ings of their own performance and the performance of theirpeers in a series of simulation scenarios, using an electronicrating system. Rating took place before the formal debrief. Inthe initial instance, the participants overestimated their per-formance; in the second instance they underestimated it.However, over time, the trainees’ perceptions became closerto that of expert raters. This study suggests a role for struc-

Vol. 2, No. 2, Summer 2007 © 2007 Society for Simulation in Healthcare 121

tured self and peer rating, although it is not clear whetherparticipants learned additional insight from their colleaguesthat they would not have gleaned from the formal facilitateddebriefing process. Self- and peer-assessments are often inac-curate, and some degree of expert direction may be required.A recent study evaluating the self-assessment skills of medicalstudents showed that low achieving students score them-selves and their peers generously.46 Standard or satisfactorystudents tend to be pretty accurate at scoring themselves andtheir peers and good students underscore themselves, but areaccurate regarding their peers illustrating the discrepancy innovice self appraisal. This is not confined to students, butapplies across all levels of experience. A recent review of phy-sician self-assessment examining 17 studies concluded a lim-ited ability to self assess.47

One approach to encouraging but also directing self andpeer debriefing may be to introduce guidelines or aids toself-assessment. A study by Zottmann et al. explored the useof collaboration scripts by observers (nonactive participantsin a simulation scenario), to aid in their ability to debriefteam members on their performance.48 A collaborationscript is an instruction tool that distributes roles and activitiesamong learners and may also include content-specific sup-port for the completion of a task. Thirty-three medical stu-dents were studied and the group was divided into observerswho received a collaboration script and those that did not. Inthis study the collaboration script illustrated individual andcollaborative elaboration of Crew Resource Management(CRM) key points and learning outcomes (CRM skills). Ob-jective (individual notes during observation phases) and sub-jective data (self-assessment and CRM skills) were analyzedfor both groups. Initial results indicated positive effects of thecollaboration script learning process. Scripted learners mademore notes regarding CRM during the observation and feltmore active in the debriefing process. Collaboration scriptsmay help make passive learning situations during observa-tion phases more active and focused, and may encourage“passive” participants to contribute to the debriefing process.Schwid et al. evaluated whether screen based anesthesia sim-ulation with a written debrief improved subsequent perfor-mance in a mannequin-based anesthesia simulator andfound it superior in preparing the participants for manne-quin-based simulation to traditional learning techniques.49

The study, however, did not examine whether the writtendebrief or the practice session on the screen based system wasresponsible for the improved performance in the manne-quin-based simulation.

Elaborating on the role of the written debrief, Petrenak,over a 20-year teaching period, encouraged his students tomaintain a journal examining their educational experiencesconcerning 8 to 12 simulations played in a semester.24 Afterattending one of his simulation workshops, students wereencouraged to write a letter on the experience which wasmailed to them 2 to 3 months later. This technique allowsreflection on learning over time free from the “ridicule orrejection” of traditional debriefing. It is also in essence a formof self-debrief. Perhaps the modern-day “blog,” although notproviding feedback as such, may also play a role in this self-

reflective and peer-appraisal approach, although it remainsto be tested a scientific fashion.

Is Video Playback Beneficial?Many sites conducting team-oriented simulations in

healthcare, whether for single disciplines or for combinedteams, use video playback as an aid in debriefing.33 In a studyevaluating the role of video playback in producing sustainedbehavioral change, Scherer et al. studied surgical residents’trauma resuscitation skills.50 Over a 6-month period, resus-citations were taped and reviewed. For the first 3 months,team members were given verbal feedback regarding perfor-mance and their behavior failed to change. In the second3-month period, video playback and verbal feedback werecombined, and within 1 month, behavior improved and wassustained for the duration of the study. The advantage ofvideo playback is not seen consistently. A study by Savoldelliet al. assessed debriefing with or without video playback intheir study of 42 anesthesia residents.42 Participants who un-derwent debriefing improved more than those who did not,but there was no difference whether the debriefer used videoplayback or not. This was similar to the findings in theBeaubien study.26 In fact, in Savoldelli’s study, there was atrend towards greater improvement in participants who re-ceived an oral debriefing rather than an oral debriefing withvideo playback. This may have been related to a reducedactual instruction time for the video playback group, or thepotential distractive nature of the video itself.42 Still, videoplayback may be useful for adding perspective to a simula-tion, to allow participants to see how they performed ratherthan how they thought they performed, and to help reducehindsight bias in assessment of the scenario. Further, theoptimal use of video is currently an art, not a science. Iflengthy or unrelated video segments are played, it may stiflediscussion of the key issues, and may detract from the focus ofthe debriefing session.

Participants often want to see video footage and enjoydoing so. In a study by Bond et al. using simulation to instructemergency medicine residents in cognitive forcing strategies,about half the participants said that they would have likedvideo playback, although it was not available.51 Interestinglyin this study, the participants received a traditional oral de-brief, but also a PowerPoint presentation and didactic lectureas part of their simulator learning experience. It seems likelythat the use of mixed media modalities and strategic use ofvideo replay may be useful, especially as participants undergorepeated simulation experiences over time and are able toextract more out of debriefing sessions. Video playback ofother simulation sessions and their debriefings may also playa role in teaching both behavioral and technical skills. A li-brary of “classic vignettes” may be a useful way of elaboratingnot only on teaching points but also in illustrating debriefingtechniques.

Does Effectiveness of Debriefing Depend on the DebriefingTechnique Used?

Debriefing is classically described as nonjudgmental in itsapproach, with the facilitator seen as colearner rather thanexpert or authority. But is this actually the best approach toensure that learning objectives are met? Do participants like

122 Fanning et al. Simulation in Healthcare

an open method of learning or do they prefer it to be moredirected? What methods leads to the greatest improvement inskill and behavior? Although very few learners will respondwell to a humiliating style of debriefing, they may find thatdebriefings that avoid analysis or criticism result in a failureto learn anything at all. It was with this in mind that Rudolphand colleagues developed the concept of debriefing with“good judgment,” which focuses on creating a context for theadult learner to learn important lessons, and incorporatethem into cognitions while amalgamating new informationwith their prior frames/life experience.2 Participants may feelthat this approach enables them to acquire knowledge in astructured manner, but having enough freedom to explorethe personal nature of their experience and incorporate whatthey learn into their own practice.

In certain instances, participants prefer a more technicaldebrief to a cognitive one. In a study involving 62 emergencymedicine residents who were randomized to receive either atechnical/knowledge debriefing (ie, one covering medicalsubject matter) or a cognitive debriefing (ie, describing theconcept of vertical line failure or other models of cognitiveerror),52 the technical debriefing was better received by par-ticipants. This may be in part due to the fact that this type ofdebriefing is more familiar to the resident, being more akin tothe traditional teaching process, where the teacher is the ex-pert and imparts their knowledge in a more linear manner.The authors of this study suggest a combination of ap-proaches may be beneficial in practice.

Do Debriefers Practice What They Preach About Debriefing?Lederman’s construct for assessing the debriefing process

looks at whether instructors actually implement the debrief-ing strategy they set out to perform.18 Just like the partici-pants who are reconciled with what they did and what theyactually thought they did when viewing video feedback, facil-itators can view their debriefing technique, and reconcilehow the debriefing session actually unfolded rather than howthey presumed it did. A study that assessed debriefings in 36US airline crews, illustrated that most facilitators talked morethan any of the crew members.33 Instructors asked a largernumber of questions, averaging close to one per minute. Halfthe content of the debriefing centered on discussing thecrew’s performance, and crew members tended to give neu-tral responses concerning their performance. Instructorsfailed to pause, or use silence to encourage crew participa-tion. The average duration of the debrief was only 31 min-utes, probably not allowing for in-depth analysis.

Dieckmann et al stress the importance of regular feedback,using video footage to appraise oneself and fellow instruc-tors.53 They have also devised a simple tool for observing andevaluating instructor practices during the debriefing process,and the roles played by participants and their degree of par-ticipation during the debriefing phase. This tool, designed forformative evaluation, feedback, and discussion uses Mi-crosoft Word to collect the desired information. The reviewerobserves the debriefing process. Instructor, participants,nurse, and consultants, for example, are assigned a letter suchas Instructor � I, Anesthesiologist � A. The reviewer pressesand holds the relevant key on their laptop as long as a partic-

ular person is talking. Because holding a key down generatesa fixed rate of repetition of that character, this can be used asa simple means to capture the duration of utterances ad-dressed to each party. The final data is entered into a spread-sheet and the proportion of talking time taken up by each indi-vidual can be viewed, as can the patterns of communication.

Feedback on debriefing performance may also be achievedby inviting other specialists in the area, such as psychologistsor anthropologists, to comment on either live or videotapedpractice. Regular appraisal of debriefing skills is necessary forevery facilitator, both on a local level, and by attending regu-lar refresher facilitation courses and workshops globally.

Translating Debriefing from the Simulator World to the RealClinical World

The concepts of briefings and debriefings apply not onlyto simulated environments but also to real operationalworlds. Aviation has stressed preflight briefings and post-flight debriefings as a method of information exchange, teambuilding, and quality management.33 The same approachesare being adapted to healthcare settings. In situ simulation in“real-life settings” or the debriefing of “real-life” events, suchas in the study by Scherer et al., illustrate the effectiveness ofdebriefing in changing patterns of behavior.50 Curricula thatteach staff physicians to debrief their subordinates are an-other example of this trend. Blum et al., in their simulationcourses for faculty anesthesiologists, include one scenariowhich involves debriefing a resident regarding a medical er-ror.54 At the end of the course and 1 year later, participantswere requested to complete a questionnaire on their experi-ence. Participants felt more equipped to debrief a residentimmediately following the simulation course than before it,and this was maintained even 1 year later. This study alsoillustrates that although faculty may debrief well after real-lifeevents, the practice is not as prevalent as residents may finduseful.

This is reiterated in a study by Tan, who audited the prac-tice of debriefing after critical incidents for anesthetic train-ees by postal survey.55 Debriefing after a critical incident wasperceived by most trainees to be useful, although 36% hadnever been debriefed. Trainees ranked their preferred con-tent for debriefing as “anesthetic issues,” followed by “psy-chologic impact,” “patient issues,” and “surgical issues.” Al-most half did not feel supported by their department after anegative outcome incident. Trainees who were debriefed feltmore supported by their senior colleagues. This study sug-gests that to have maximum effect, these facilitated team de-briefings should be performed after real patient care situa-tions, not just training exercises. This would reinforce thelessons learned in simulation and have the best chance ofimproving behavior, and strengthening departmental cohe-siveness between staff and residents.

Future Research on DebriefingThis review illustrates some of the gaps that exist in our

understanding of the role of debriefing in simulation basedlearning: fundamental issues such as whether debriefing isalways required and, if it is, what are the most effective tech-niques to achieve a particular learning objective? How orshould debriefing in teams differ from individual debriefing,

Vol. 2, No. 2, Summer 2007 © 2007 Society for Simulation in Healthcare 123

or debriefing novices differ from debriefing more experi-enced participants? How do we effectively evaluate the suc-cess of particular debriefing techniques and the use of auxil-iary aids, such as video playback in the learning process as awhole? A primary area of research would be the developmentof models and theories of debriefing specifically within thefield of simulation-based learning. Analysis and evaluation ofdebriefing models using common metrics, both quantitativeand qualitative, would be beneficial to compare with othereducational methods and techniques. Large, well-designed,high-powered collaborative studies within the simulationcommunity both medical and nonmedical may provide anavenue to explore some of the current pertinent questions insimulation-based learning.

CONCLUSIONIt is widely accepted that debriefing is the “heart and soul”

of the simulation experience.40 Currently, there is an increas-ing body of work exploring the role and effectiveness of de-briefing in an objective manner in the learning process. Todate, only a small proportion of this has reached peer-reviewjournal publication, but the ever-increasing presentations oftechniques, methods, and assessment of the process at inter-national meetings on simulation in healthcare are encourag-ing.

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21. Gibb J: Defensive communication. J Communication 1961;11:141–148.

22. Savoldelli GL, Naik VN, Hamstra SJ, et al. Barriers to the use ofsimulation-based education. Can J Anesth 2005;52 944–950.

23. Kolb DA: The learning style inventory LSI Learning style inventoryversion 3. Boston: TRG Hay/McBer Training Resources Group, 1999.

24. Petranek CF: Written debriefing: The next vital step in learning withsimulations. Simul Gaming 2000;31:108–118.

25. Steinwachs B: How to facilitate a debrief. Simul Gaming 1992;23:186–195.

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29. Petranek C: Maturation in experiential learning: Principles ofsimulation and gaming. Simul Gaming 1994;513–522.

30. Wilhelm J: Crew member and instructor revaluations of lineorientated flight training. Proceedings of the 6th internationalsymposium on aviation psychology, 1991:362–367.

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32. McLean M: What can we learn from facilitator and studentperceptions of facilitation skills and roles in the first year of a problembased learning curriculum. Med Educ 2003;3:1–10.

33. Dismukes R, Smith G: Facilitation and debriefing in aviation trainingand operations. Aldershot; UK: Ashgate, 2000.

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39. Rudolf JW, Talyor SS, Foldy EG: Collaborative off-line refection. Away to develop skill in action science and action inquiry. In Handbookof Action Research. Thousand Oaks, CA: Sage, 2000.

40. Rall M, Manser T, Howard S: Key elements of debriefing for simulatortraining. Eur J Anaesthesiol 2000;17:516–517.

41. Qudrat-Ullah H: Improving dynamic decision making through

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debriefing: An empirical study. Proceedings IEEE InternationalConference on advanced learning technologies. Finland: ICALT, 2004.

42. Savoldelli GL, Naik NV, Park J, et al: Value of debriefing duringsimulated crisis management. Anesthesiology 2006;105:279–285.

43. Dismukes RK, Gaba DM, Howard SK: So many roads: facilitateddebriefing in healthcare. Simul Healthcare 2006;1:23–25.

44. Butler RE: Loft: Full-motion simulation as crew resource managementtraining. Cockpit resource management. San Diego: Academic Press, 1993.

45. Foraida MI, DeVita MA, Schaefer JJ: Evaluation of an electronicsystem to enhance crisis resource management training. SimulHealthcare 2006;1:85–91.

46. Langendyk V: Not knowing that they do not know: self-assessmentaccuracy of 3rd year medical students. Med Educ 2006;40:173–177.

47. Davis DA, Mazmanian PE, Fordis M, et al: Accuracy of physician self-assessment compared with observed measures of competence: asystematic review. JAMA 2006;296:1094–1102.

48. Zottmann J, Dieckmann P, Rall M, et al: Fostering simulation-basedlearning in medical education with collaboration scripts. SimulHealthcare 2006;1:193.

49. Schwid HA, Rooke AG, Michalowski P, et al: Screen based anesthesiasimulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teach Learn Med 2001;13:92–96.

50. Scherer LA, Chang MC, Meredith JW, et al: Videotape review leads torapid and sustained learning. Am J Surg 2003;185:516–520.

51. Bond WF, Dietrick LM, Arnold DC, et al: Using simulation to instructemergency medicine residents in cognitive forcing strategies. AcadMed 2004:79:438–446.

52. Bond WF, Deitrick LM, Eberhardt M, et al: Cognitive versustechnical debriefing after simulation training Acad Emerg Med2006;13:276–283.

53. Dieckmann P, Striker E, Rall M: Methods for formative evaluations ofdebriefing as a tool for feedback and improvement. Simul Healthcare2006;1:190.

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Vol. 2, No. 2, Summer 2007 © 2007 Society for Simulation in Healthcare 125

Featured Article

Standards of Best Practice: SimulationStandard VI: The Debriefing Process

Sharon Decker, PhD, RN, ANEF, FAANa, Mary Fey, MS, RNb,Stephanie Sideras, PhD, RN, C.A.P.A.c, Sandra Caballero, MSN, RNd,Leland (Rocky) Rockstraw, PhD, RNe, Teri Boese, MSN, RNf,Ashley E. Franklin, MSN, RN, CCRN, CNEg, Donna Gloe, EdD, RN-BCh,Lori Lioce, DNP, FNP-BC, CHSE, FAANPi, Carol R. Sando, PhD, RN, CNEj,Colleen Meakim, MSN, RNk, Jimmie C. Borum, MSN, RN, CNSl,*aProfessor and Director of The F. Marie Hall SimLife Center, Texas Tech University Health Science Center, School ofNursing, Lubbock, TX 79430, USAbAssistant Professor, Director, Clinical Simulation Laboratory, University of Maryland School of Nursing, Baltimore, MD21201, USAcInstructor, Oregon Health & Science University School of Nursing Ashland Campus, Ashland, Ore 97520, USAdInstructor and Coordinator of The F. Marie Hall SimLife Center, Texas Tech University Health Sciences Center, Lubbock, TX79430, USAeAssistant Dean, Simulation, Clinical & Technology Academic Operations; Associate Clinical Professor, Drexel UniversityCollege of Nursing and Health Professions, Philadelphia, PA 19104, USAfAssociate Professor, Clinical, Director Center for Simulation Innovation, University of Texas Health Science Center at SanAntonio, School of Nursing, San Antonio, TX 78229, USAgInstructor and Simulation Specialist, Oregon Health and Science University, School of Nursing, Portland, OR 97201, USAhAssistant Professor, Coordinator of Simulation Center, Missouri State University, Springfield, MO 65897, USAiClinical Assistant Professor and Simulation Coordinator, The University of Alabama in Huntsville, College of Nursing,Huntsville, AL 35802, USAjAssociate Professor, Delaware State University, College of Education, Health, and Public Policy, Department of Nursing,Dover, DE 19901, USAkDirector, Simulation and Learning Resources, Villanova University, College of Nursing, Villanova, PA 19085, USAlAssistant Professor of Professional Practice, Director, Health Professions Learning Center, Harris College of Nursing andHealth Sciences, Texas Christian University, Fort Worth, TX 76129, USA

KEYWORDSdebrief;reflection;facilitation;reflective thinking;clinical judgment/reasoning

Abstract: All simulation-based learning experiences should include a planned debriefing session aimedtoward promoting reflective thinking. Learning is dependent on the integration of experience andreflection. Reflection is the conscious consideration of the meaning and implication of an action, whichincludes the assimilation of knowledge, skills, and attitudes with pre-existing knowledge. Reflection canlead to new interpretations by the learner. Reflective thinking does not happen automatically, but it can betaught; it requires time, active involvement in a realistic experience, and guidance by an effective

No extramural funding or commercial financial support was received

during the development of this article.

* Corresponding author and Chair, INACSL Standards Committee:

j.borum@tcu.edu (J. C. Borum).

1876-1399/$ - see front matter � 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ecns.2013.04.008

Clinical Simulation in Nursing (2013) 9, e26-e29

www.elsevier.com/locate/ecsn

facilitator. The skills of the debriefer are important to ensure the best possible learning; learning withoutguidance could lead the learner to negatively transfer a mistake into their practice without realizing it hadbeen poor practice, repeat mistakes, focus only on the negative, or develop fixations. Research providesevidence that the debriefing process is the most important component of a simulation-based learningexperience.

Cite this article:Decker, S., Fey, M., Sideras, S., Caballero, S., Rockstraw, L. (R.), Boese, T., Franklin, A. E., Gloe, D.,Lioce, L., Sando, C. R., Meakim, C., & Borum, J. C. (2013, June). Standards of Best Practice: SimulationStandard VI: The debriefing process. Clinical Simulation in Nursing, 9(6S), S27-S29. http://dx.doi.org/10.1016/j.ecns.2013.04.008.

� 2013 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Statement

All simulation-based learning experiences should includea planned debriefing session aimed toward promotingreflective thinking.

Rationale

Learning is dependent on the integration of experience andreflection. Reflection is the conscious consideration of themeaning and implication of an action, which includesthe assimilation of knowledge, skills, and attitudeswith pre-existing knowledge. Reflection can lead to newinterpretations by the learner. Reflective thinking does nothappen automatically, but it can be taught; it requires time,active involvement in a realistic experience, and guidanceby an effective facilitator. The skills of the debriefer areimportant to ensure the best possible learning; learningwithout guidance could lead the learner to negativelytransfer a mistake into their practice without realizing ithad been poor practice, repeat mistakes, focus only on thenegative, or develop fixations. Research provides evidencethat the debriefing process is the most important componentof a simulation-based learning experience.

Outcome

Integration of the debriefing process into simulation-basedexperience enhances learning and heightens participantself-confidence. Debriefing promotes understanding andsupports transfer of knowledge, skills, and attitudes witha focus on best practices to promote safe, quality patient care.

Criteria

To achieve the desired outcomes, the effective debriefingprocess is:

1. Facilitated by a person(s) competent in the process ofdebriefing.

2. Conducted in an environment that is conduciveto learning and supports confidentiality, trust, opencommunication, self-analysis, and reflection.

3. Facilitated by a person(s) who observes the simulatedexperience.

4. Based on a structured framework for debriefing.5. Congruent with the participants’ objectives and out-

comes of the simulation-based learning experience.

Guidelines

Criterion 1: Facilitated by a Person(s) Competentin the Process of Debriefing

Guideline: Identify the process to achieve competency indebriefing.

Guideline Statement: Debriefing is a learner-centeredreflective conversation. It is intended to assist learners inexamining the meaning and implications of actions takenduring a simulated experience. Through this process ofunderstanding, newknowledge canbe created.Reflective think-ing does not happen automatically and requires guidance by aneffective debriefing facilitator, commonly called a debriefer.Debriefing facilitators require skill both in diagnosing learningneeds andmanaging optimal group processes to adjust the levelof facilitation to that which is required by the group. For bestoutcomes during simulation-based experiences, debriefersshould have formal training and competency assessment.

The debriefer should:

� Understand best practices in debriefing with regard tostructuring the format of the debriefing and facilitatingreflective discussion.

� Acquire specific education provided by a formalcourse, a continuing education offering, or targetedwork with an experienced mentor.

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� Validate competence through the use of an establishedinstrument.

� Validate competence through input from both learnersand experienced debriefers.

� Actively maintain debriefing skills through practice insimulation-based experiences.

Criterion 2: Conducted in an Environment ThatSupports Confidentiality, Trust, OpenCommunication, Self-Analysis, and Reflection

Guideline:Create a safe environment for participant debriefing.Guideline Statement: Although active learning educa-

tional methods such as simulation promote learning, thesestrategies may be stressful and cause feelings of anxiety.

Therefore, to create a safe environment for the debrief-ing process, in an effort to achieve desired outcomes, thedebriefer should:

� Orient the participants to the overall objectives andpurposes of the debriefing process.

� Establish expectations regarding confidentiality ofparticipants’ work, the content of the simulationscenario, and the content of the debriefing process.

� Develop rules of participant conduct concerningconstructive, honest, yet respectful feedback.

� Demonstrate positive regard for participants.� Encourage participants’ reflection related to personalculture, background, experiences, personality, skills,and knowledge.

� Use verbal and nonverbal supportive demeanor toencourage discussion.

� Allow sufficient time for the early reaction phase of thedebriefing process to elicit the participants’ emotionalresponse and their primary concerns prior to engagingin an analysis of actions.

� Explore the participants’ perspectives and understand-ings of the situation to close gaps between actual anddesired performance.

� Engage both participant observer and active partici-pants in debriefing to support collaborative learning.

Criterion 3: Facilitated by a Person(s) WhoObserves the Simulated Experience

Guideline: Identify the facilitator’s responsibilities duringthe debriefing process.

Guideline Statement: The role of the facilitator duringthe debriefing process is to guide the participants as theyreflect on the events of the simulated experience and theactions taken or not taken during the event. The discussionshould be guided by the participant objectives with the aimof closing the gap between the desired and actual perfor-mance of the participants through constructive feedback ordebriefing. (See ‘‘Standard III: Participant Objectives,’’)

The debriefer should:

� Establish a climate of professional respect, includinga requirement for confidentiality related to the contentof the debriefing discussions.

� Outline the process for debriefing, including theexpectation that the discussion will be driven by theparticipants as they critically analyze their ownperformance.

� Facilitate participants’ engagement in the reflectiveprocess.

� Adjust the level of facilitation needed to engage everyparticipant in discussion.

� Provide constructive feedback or debriefing based onparticipants’ decisions and actions, including reinforcingpositive behaviors, correcting misunderstandings, andclarifying cognitive frames that led to incorrect decisions.

� Assist participants in conceptualizing how the learningconstructed during the simulation and debriefing can beapplied to future clinical situations.

� Summarize learning at the end of the debriefing process

Criterion 4: Based on a Structured Frameworkfor Debriefing

Guideline: Identify the structural elements of debriefing toinclude the optimal time and duration required to achievethe objectives.

Guideline Statement: The optimal time length fora debriefing session depends on the objectives and type ofsimulation-based experiences. An experience designed fornovice-level critical thinking and skills demonstration mayrequire only constructive feedback and guided reflection.Complex simulation-based experiences that require clinicaljudgment or reasoning while demonstrating skill compe-tency or are emotionally charged require debriefing sessionsof longer duration. The longer time period is required to fa-cilitate deeper thinking and critical reflection. Additionally,a period of self-reflection after the debriefing session may benecessary to achieve desired objectives. Therefore, theoptimal time and duration of debriefing should be flexible.

The debriefer should:

� Create a safe and supportive environment (SeeCriteria 5).� Use the appropriate style of debriefing (including videoplayback) based on participant objectives (SeeCriteria 4).

� Allow progression through the phases of debriefing(reaction, analysis, and summary).

� Allow unexpected topics to be addressed.� Facilitate appropriate clinical judgment, reasoning, andreflection.

� Allow facilitation to be modified based on assessedparticipant needs and the impact of the experience.

� Allow for postdebriefing activities that promote self-reflection and critique.

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Criterion 5: Congruent with the Participants’Objectives and Outcomes of the Simulation-BasedLearning Experience

Guideline: Focus debriefing on the participant objectivesand outcomes.

Guideline Statement: Debriefing should be based onpreset participant objectives and the outcomes of thesimulation-based experience. Participant objectives guidethe development and appropriate implementation of theexperience, whereas outcomes provide an assessment ofthe participant’s performance and clinical judgment orreasoning based on the predetermined objectives orcritical events that occurred during the simulation-basedexperience.

The debriefer should:

� Consider participant objectives in the debriefing session.� Facilitate participant’s identification of strengths inperformance and clinical judgment or reasoning.

� Identify performance gaps based on the outcomes of thesimulation-based experience at the end of the debriefingsession.

� Recommend activities to alleviate identified perfor-mance gaps at the end of the debriefing session.

Original INACSL Standard VI Reference

The INACSL Board of Directors. (2011, August).Standard VI: The debriefing process. Clinical Simulationin Nursing, 7, s16-s17.

Supporting Materials

Arafeh, J. R., Hansen, S., & Nichols, A. (2010). Debriefing in simulated-

based learning: Facilitating a reflective discussion. Journal of Perinatal

& Neonatal Nursing, 24(4), 302-309.

Boud, D., Koegh, R., & Walker, D. (1985). Promoting reflection in learn-

ing: A model. In D. Boud, R. Keogh, & D. Walker (Eds.), Reflection:

Turning experience into learning (pp. 18-40). London: Kogan Page.

Decker, S., & Dreifuerst, K. T. (2012). Integrating guided reflection into

simulated learning experiences. In P. Jeffries (Ed.), Simulation in nursing

education from conceptualization to evaluation (2nd ed.). (pp. 91-104)

New York: NLN.

Decker, S., Gore, T., & Feken, C. (2011). Simulation. In T. Bristol, &

J. Zerwekh (Eds.), Essentials of E-learning for nursing educators. Phil-

adelphia: F.A. Davis Company. pp. 277-294.

Dismukes, R. K., & Smith, G. M. (2000). Facilitation and debriefing in

aviation training and flight operations. Burlington, VT: Ashgate.

Dreifuerst, K. T. (2009). The essentials of debriefing in simulation learn-

ing: Concept analysis. Nursing Education Perspectives, 30, 109-114.

Dreifuerst, K. T., & Decker, S. (2012). Debriefing: An essential component

for learning in simulation pedagogy. In P. Jeffries (Ed.), Simulation in

nursing education from conceptualization to evaluation (2nd ed.). (pp.

105-130) New York: NLN.

Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in

simulation-based learning. Simulation in Healthcare, 2, 115-125.

Gaba, D. M. (2004). The future vision of simulation in healthcare. Quality

Safety in Health Care, 13, i2-i10.

Glaze, J. (2002). Stages in coming to terms with reflection: Student

advanced nurse practitioners’ perceptions of their reflective journeys.

Journal of Advanced Nursing, 37, 265-272.

Imperial College of London. (2012). The London handbook of debriefing.

London: National Health Services.

Murphy, J. I. (2004). Using focused reflection and articulation to promote

clinical reasoning: An evidence-based teaching strategy. Nursing and

Health Care Perspectives, 25, 226-231.

Neill, M. A., & Wotton, K. (2011). High-fidelity simulation debriefing in

nursing education: A literature review. Clinical Simulation in Nursing,

7(5), e1-e8. http://dx.doi.org/10.1016/j.ecns.2011.02.001.

Paget, T. (2001). Reflective practice and clinical outcomes: Practitioners’

views on how reflective practice has influenced their clinical practice.

Journal of Clinical Nursing, 10(2), 204-214.

Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006).

There’s no such thing as ‘‘nonjudgmental’’ debriefing: A theory and

method for debriefing with good judgment. Simulation in Healthcare,

1(1), 49-55.

Rudolph, J. W., Simon, R., Raemer, D. B., & Eppich, W. J. (2008). De-

briefing as formative assessment: Closing performance gaps in medical

education. Academic Emergency Medicine, 15(11), 1010-1016.

Wong, F. K. Y., Kember, D., Chung, L. Y. F., & Yan, L. (1995). Assessing

the level of student reflection from reflective journals. Journal of

Advanced Nursing, 22(1), 48-57.

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Review Article

Best Practice Recommendations for Debriefing inSimulation-Based Education for AustralianUndergraduate Nursing Students: An IntegrativeReview

Karen Hall, RPN, MMentlHlth, Dip VET, Cert IV TAEa,*,Kathleen Tori, MHSc, MNP, CCRN, GradDip VET, MACN, FACNPbaCentre for Learning and Teaching Melbourne Polytechnic, Yarra Bend Rd, Fairfield, Victoria, AustraliabEmergency Nurse Practitioner, Department of Rural Nursing and Midwifery, La Trobe Rural Health School, La TrobeUniversity, PO Box 199, Bendigo, Victoria, Australia

KEYWORDSsimulation;simulation-basedtraining;

debrief;critical thinking;nursing students;health professionals

AbstractBackground: An integral and possibly the most important component of the simulation-based learning isthe debriefing process. It is desirable to then examine the literature to determine best practice guidelines.Method: This integrative literature review searched several relevant online databases including JoannaBriggs Institute, Cochrane Library, MEDLINE, CINAHL, Psych Info, Science Direct, ProQuest, Ovid, andWeb of Science. Libsearch, Google Scholar, and Google were also searched to capture relevant literatureand research.As a systematic reviewof randomizedcontrol studies already existed in JoannaBriggs Institute(2012), it was decided to include that study and limit the search to only those articles published after 2012.Results: Therewereeight predominant themes that emerged from the literature reviewed regarding thebestpractice guidelines for debrief phase in simulation-based education: (a) types of debriefing (video assistedand facilitator only), (b) debrief in simulation versus postsimulation, (c) environment in which the debrieftakes place, (d) the person who should facilitate the debrief, (e) assessment and training of the person whodebriefs, (f) identification of the learning outcomes, (g) method of debrief, and (h) structure of the debrief.Conclusion: Following an extensive literature review, it was established that there were eight best practicerecommendations to facilitate the debrief process. The integrative review strongly suggested that a safe,structured debrief following the simulation immersion is aligned to best practice. Best practice in simulationis conducive to promoting clinical psychomotor skills and knowledge.

Cite this article:Hall, K., & Tori, K. (2017, January). Best practice recommendations for debriefing in simulation-based education for australian undergraduate nursing students: An integrative review. Clinical Simu-lation in Nursing, 13(1), 39-50. http://dx.doi.org/10.1016/j.ecns.2016.10.006.

� 2016 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Clinical Simulation in Nursing (2017) 13, 39-50

www.elsevier.com/locate/ecsn

Author statement: Study design: KH, data collection and analysis: KH,

critical review: KT, and manuscript preparation: KH and KT.

* Corresponding author: karenhall@melbournepolytechnic.edu.au

(K. Hall).

1876-1399/$ - see front matter � 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ecns.2016.10.006

Introduction

The use of simulation in the education of health pro-fessionals began in the 1960s and has evolved at anunprecedented pace (Levett-Jones & Lapkin, 2014). Simula-

tion is defined as a techniqueto ‘‘replace or amplify realexperiences with guided ex-periences, often immersivein nature, that evoke or repli-cate substantial aspects ofthe real world in a fullyinteractive fashion’’ (Gaba,2004, p. i2). In some coun-tries, it is even a mandatedpart of the curricula, due inpart to the increasedcomplexity of patients, theneed to manage risk and pa-tient safety, and the intense

competition for quality clinical placements for students(Anderson, Bond, Holmes, & Cason, 2012).

An integral and possibly the most important componentof simulation-based learning is the debriefing process(Dreifuerst, 2012; Edgecombe et al., 2013; HealthWorkforce Australia, 2010). Within the debriefing process,theory is connected to practice; reflection, critical thinking,and clinical reasoning take place; and learning is maxi-mized (Edgecombe et al., 2013).

Debrief, despite being such an important area, andpotentially the most important area for the innovative,educational pedagogy of simulation-based-learning, has notreceived the attention it deserves. This integrative reviewattempts to synthesize the evidence and determine bestpractice in simulation.

Background and Rationale

Simulation-based learning has been adopted by educationinstitutions at a remarkable pace, and it is a mandated partof nursing curricula in New Zealand and the United States(Edgecombe et al., 2013). In Australia, Health WorkforceAustralia (HWA) was established in 2008 by the Councilof Australian Governments, with the predominant aim ofdelivering national health reform. An overarching aim ofthis reform was to expand health simulated learning envi-ronments by optimizing simulation training experiencesto enhance the development of theoretical skills and clin-ical competencies required by health professionals pre-and post-registration (HWA, 2010). This was as a directresult of the increasing concerns for patient safety andthe decreased opportunity for experiential learning in aclinical placement environment (Imperial College ofLondon, 2012). It is important to note that the use of

simulators alone does not equate to high-quality training,and it is the role of feedback and debriefing that enablesthe learner to integrate their learning experience (ImperialCollege of London, 2012). Debriefing provides the processwhereby the students develop their clinical reasoningthrough reflection and metacognition (Mariani, Cantrell,Meakim, Prieto, & Dreifuerst, 2013). Effective debriefinglinks theory to practice and research and enables studentsto critically think and to intervene professionally in com-plex situations (Anderson et al., 2012; Jeffries, 2005). De-briefing is elevated to the most important component of thesimulation-based learning experience (Decker et al., 2013).It is an ‘‘integral part of the experience and creates the plat-form where critical thinking and learning integration takesplace’’ (Levett-Jones & Lapkin, 2014, p. 1). Despite de-briefing being common practice postsimulation, conflictingviews exist as to what is most appropriate or best practice.Through an integrative literature review, this article willaim to establish best practice for debriefing in simulationusing high-fidelity mannequins and standardized patients.

Research Question

The research question ‘‘What is the best practice fordebriefing simulation-based education for undergraduatenursing students?’’ was used to guide the research strategy.An approach identified by Sackett et al. (1997)dPI-COdwas used to describe the elements of the researchquestion to be considered: P, for patient or problem; I,intervention or interest; C, for comparison; and O, foroutcome.

In relation to this integrative review, these componentswere as follows: P ¼ nursing students, I ¼ debriefing withsimulation-based education, C ¼ no comparison wasrequired as the review was aimed at determining bestpractice, and O ¼ to identify best practice guidelines fordebrief facilitation in simulation-based learning.

Search Strategy

This integrative literature review searched several relevantonline databases including Joanna Briggs Institute (JBI),Cochrane Library, MEDLINE, CINAHL, Psych Info, Sci-ence Direct, ProQuest, Ovid, and Web of Science. Lib-search, Google Scholar, and Google were also searched tocapture relevant literature and research (Figure).

The search terms used included simulation, debrief, andhealth professionals along with variations of these wordsthat resulted in 2,434 responses. The terms were then com-bined using the Boolean operator ‘‘AND’’ and furtherreduced. As a systematic review of randomized controlstudies already existed in JBI (2012), it was decided toinclude that study and limit the search to only those articlespublished after 2012.

Key Points� Debriefing is anessential componentof simulation-basedlearning.

� Debriefing requires astructure framework.

� Video-assisted andfacilitator onlydebrief are bothequally effectivetechniques.

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The resulting abstracts of 435 studies were included ifthey contained all defined search terms. One seminal articlewas also included in the review that was Jeffries (2005)framework for simulation. Studies were then excluded ifthey contained only computer-based simulation, low-fidelity simulation, and military or aviation studies. This re-sulted in 21 articles being integrated in the review (Table 1).

Data Analysis

All articles that met the inclusion criteria were analyzedseparately by the first author. The predominant findings ofeach article were then compared across all articles toidentify similarities and differences in debriefing tech-niques, targeted student groupings, and recommendationsand/or guidelines. The Joanna Briggs Institute Hierarchy ofEvidence (2014) was used to guide the author in deter-mining the rigor and methodological quality of the includedliterature and assist in establishing clinical bottom line and

best practice guidelines. It is important to note that theauthor is not a JBI reviewer (Table 2).

Results

Given the range of debriefing methods used and the greatvariation of outcomes, the findings were synthesized andpresented in themes. Essentially, the results of this integra-tive review found there were eight predominant themes thatemerged from the literature reviewed regarding the bestpractice guidelines for debrief phase in simulation-basededucation. These themes included (a) types of debriefing(video assisted and facilitator only), (b) debrief in simula-tion versus postsimulation, (c) environment in which thedebrief takes place, (d) the person who should facilitatethe debrief, (e) assessment and training of the personwho debriefs, (f) identification of the learning outcomes,(g) method of debrief, and (h) structure of the debrief.

Studies included in Levett-Jones and Lapkin systema c review (2012)

RCT’s (n=10) 2000-2011

(n=2419) studies iden fied throughdatabase searching

2012-2014

(n=15) studies iden fied

through othersources

(n=2008) studies excluded

a er adding the Boolean

operator ‘And’

(n=435) studies included and abstracts

read

(n=414) studies

excluded as they

were non -English,

computer -based

simula on, low

fidelity simula on,

studies involving

military or avia on

only. Studies

published prior to

2012

Total of (n=21) studies included in review

Figure Search progression.

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These themes are briefly discussed in the followingsections.

Type of Debriefing

A systematic review by Levett-Jones and Lapkin (2012)found that four of six randomized control studies identifiedno statistically significant difference between facilitator-only and video-assisted debriefing in achieving learningoutcomes. Similar results were found in a systematic re-view on simulation-based training in anesthesiology(Lorello, Cook, Johnson, & Brydges, 2014).

A study by Grant, Moss, Epps, and Watts (2010)involving 40 anesthetia and nursing students who wererandomly assigned to experimental and control groupsfound no statistical difference on total performance scoresbetween the experimental group receiving video-assisted

debriefing and the control group that received facilitator-assisted debriefing. Similarly, a study by Chronister andBrown (2012) on 37 undergraduate nursing students partic-ipants also randomly assigned participants to a controlgroup who undertook 30 minutes of facilitated debrief oran experimental group with video-assisted debrief. The out-comes of interest were response times, quality of skills, andknowledge retention. Response time was higher in theexperimental group, but retention was higher in the controlgroup. Quality of skills remained the same for both groups(Levett-Jones & Lapkin, 2012).

These findings were further supported in a study byReed, Andrews, and Ravert (2013) that used a quasi-experimental design to compare the experiences of 64 un-dergraduate nursing students who were participating insimulations that were part of their intensive care course.These students had previously participated in six to seven

Table 1 Search Strategy

Electronic Databases (n ¼ 426) Search Engines (n ¼ 9)

JBI (n ¼ 1)Cochrane (n ¼ 0)MEDLINE (n ¼ 138)ProQuest (n ¼ 56)Web of Science (n ¼ 22)CINAHL (n ¼ 28)Psych Info (n ¼ 33)Science direct (n ¼ 36)Ovid (n ¼ 103)

TRIP (n ¼ 0)NICE (n ¼ 1)Google (n ¼ 1)Google Scholar (n ¼ 2)Libsearch (n ¼ 3)Library search (n ¼ 2)

Keywords

SimulationSimulation based-trainingClinical simulationHealthcare simulation

DebriefingDebriefReflectionReflective thinkingClinical reasoning

Critical thinkingCritical reasoningClinical judgmentFeedback

Health professionalsMedical studentsNursing studentsPsychologists

Inclusion Criteria Exclusion Criteria

EnglishPublished between 2012 and 2014

Non-EnglishComputer-based simulationLow-fidelity simulationStudies involving military or aviation only.Studies published prior to 2012

Final Included Articles (n ¼ 21) Organizational and Government Literature/Guidelines

JBI (n ¼ 1)Cochrane (n ¼ 0)MEDLINE (n ¼ 2)ProQuest (n ¼ 4)Web of Science (n ¼ 3)CINAHL (n ¼ 0)Psych Info (n ¼ 0)Science direct (n ¼ 5)Ovid (n ¼ 2)Google scholar (n ¼ 1)

HWAAKO National Centre for tertiary teaching excellenceImperial College London

Note. HWA ¼ Health Workforce Australia; JBI ¼ Johanna Briggs Institute.

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Table 2 Review of the Literature

Author/Year Purpose of the Study Methodology/Sample Results

Anderson et al. (2012) To describe how conference participantsrated their level of proficiency withsimulation skills and how these skillswere obtained and preferred learningstyles

Descriptive study surveying 58 individualswho attended a simulation conference inSt Louis, MO (2009), majority 95% usingsimulation-based learning

Learning from someone skilled insimulation was the best way to learn theskills

Buckley et al. (2012) To compare student perceptions pre andpost interprofessional simulation

Qualitative pre- and postsimulation survey(n ¼ 191), medical students (n ¼ 86),nursing students (n ¼ 71), ODP,physiotherapy and radiology students(n ¼ 34)

Increased understanding and confidenceMost students reported video feedback washelpful

All students reported verbal feedback frompeers, role-players, and facilitators wasuseful

Recommended a need for a safeenvironment for feedback

Decker et al. (2013) To define the standard of best practice insimulation

Guidelines All simulation experiences should include aplanned debriefing session

Facilitators should be competent in theprocess of debriefing

The environment should supportconfidentiality

Facilitated by the person who observes theexperience

Based on a structured frameworkIt should be congruent with participantsobjectives and outcomes

Dreifurst (2012) The relationship of DML on development ofclinical reasoning skills in nursing

Exploratory quasi-experimental pre- andposttest study (n ¼ 238)

DML is successful in teaching nurses’clinical reasoning skills

Dufrene and Young (2014) Explore options for debriefing Literature review (n ¼ 9) Recommended teacher-assisted debriefThe person who facilitates the SLE shouldperform the debrief

The facilitator should be trained in debriefEdgecombe et al. (2013) To establish guidelines for teaching and

learning using clinical simulation forundergraduate nurses

Literature review of 13 studies from policy,regulatory and strategic literature, orsystematic and literature reviews

Debriefing is essential to simulation-basedlearning.

Debriefing needs to be structuredDebrief needs to be based on learningoutcomes

Debrief needs to be in a safe environmentThe debrief person needs knowledge aboutdebriefing

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Table 2 (continued )

Author/Year Purpose of the Study Methodology/Sample Results

Gardner (2013) An introduction to debriefing and anapproach to evaluate debriefing skills ofthe facilitators

Narrative discussion Debriefing is required post scenarioThree-stage reaction, understanding, andsummary

A safe environment is neededConfidentiality is requiredAcknowledging the skills learnt is neededUse of DASH tool to rate the debriefer

Health Workforce Australia (2010) Review of simulation-based learning innursing

Literature review Increased psychomotor skillsNeed for enhanced collaboration, sharedresources, and the development of apool of ‘‘best practice’’ resources forgeneral usage (e.g., scenarios, software)and where a community can shareexperiences and learn from theexperience of others

Imperial College of London (2012) Evidence-based, user-informed tools forconducting and assessing debriefings inclinical and simulated settings

Handbook for debriefing Identified SHARP tool for feedback anddebrief

OASD for assessing quality of debriefJaeger (2012) To determine how high-fidelity simulation

enhances clinical reasoning skills inundergraduate nursing programs

Qualitative design: case study (n ¼ 10).Interviews conducted with five schoolsof nursing one faculty member and onesimulation facilitator from each school

Debriefing was considered the mostimportant component of the simulationprocess

Debriefing enhances clinical reasoningJeffries (2005) A framework to design, implement, and

develop simulation in nursingDescriptive Jeffries model for simulation (framework)

Debriefing takes place at the end of thesession

Kelly et al. (2014) Explore students’ opinions about ‘‘whatmatters most’’ in the design and deliverof simulation

Quantitative descriptive study (n ¼ 150) Simulation enhances learningFacilitated debrief enhances criticalthinking

Reflection enhances critical thinking andranked second to debriefing

Levett-Jones and Lapkin (2012) To identify, appraise, and synthesize thebest evidence for debriefing insimulation-based learning

Systematic review of 10 randomizedcontrolled studies, 2002-2011

No clinical or practical differences inoutcomes between facilitator only orfacilitator and video-enhanceddebriefing

Levett-Jones and Lapkin (2014) To identify, appraise, and synthesize thebest evidence for debriefing insimulation-based learning

Systematic review of 10 randomizedcontrolled studies, 2000-2011

Debrief contributes to effective learningVideo-assisted leaning offers noeducational advantage over instructoronly debriefing

Lorello et al. (2014) Comparison between simulation-basedlearning, no intervention, and

Systematic review on PRISMA standards ofquality for meta-analyses (n ¼ 77)

Little difference between video assistedand facilitator only debriefing

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nonsimulation instructional approachesin anesthesiology

High-fidelity mannequins did notnecessarily add value to the training

Lusk (2013) Explores strategies that optimize aftersimulation as a means to promoteclinical judgment in nursing students

Literature review 2004-2012 and 22articles are included in the review

Simulation provides the context to developpractical knowledge

Debrief the context to organizeinformation so that it can be applied inclinical situations

Developed a framework of reflecting,noticing, interpreting, and responding(Tanners model)

Mariani et al. (2013) Explores strategies to debrief and promoteclinical reasoning in nursing students

Literature review of 27 articles including 3systematic reviews

Debriefing is needed to develop clinicalreasoning

It needs to be structuredSmall group sizesClear learning outcomesSufficient time allotted

Pivec (2011) To design a debriefing tool to be used aftersimulation

Literature review Safe environment required for debriefingDebrief should occur immediately after thesimulation

The facilitator needs to be competentConfidentiality required

Reed et al. (2013) To evaluate the nursing students’experience during debriefing usingvideo-assisted debriefing or facilitator-only debriefing

Quasi-experimental study design. Nursingstudents (n ¼ 64)

Neither debriefing method was superiorwith video of facilitator only

Rudolph et al. (2013) Strategies to avoid the task-versus-relationship dilemma and debrief moreeffectively

Case study Nonjudgmental, honest feedback.Normalizing difficulties

Williamson et al. (2013) To describe a simulated general practiceclinic for medical students

Case study This clinic offers students to engagewithout observation and SPs givefeedback. Student feedback isoverwhelmingly positive.

Note. DML ¼ debriefing for meaningful learning; OASD ¼ objective structured assessment of debriefing; ODP ¼ Operating Department Practice; PRISMA ¼ Preferred Reporting Items for Systematic Reviews

and Meta-Analyses; SLE ¼ simulated learning environment; SP ¼ simulated patients.

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simulations with facilitator-only debriefs. None had partic-ipated in video-assisted debrief. They were randomizedinto two groups: 32 participants who received debriefingwith video and 32 who received facilitator-only debriefing.The simulation went for 1 hour and debrief for 25 minutes,with 5 minutes allowed to get to the debrief room. Datawere collected using the ‘‘debriefing experience scale,’’which consisted of 20 questions divided in 4 subscales.Statistically significant differences were found in only 3out the 20 items Debriefing with video had the highermeans in two of the questions and debriefing alone inone. After analysis with an independent sample t-test, theauthors concluded that neither debriefing with video or de-briefing alone is superior (Reed et al., 2013).

Debrief in Simulation Versus Post Simulation

Van Heukelom, Begaz, and Treat (2010) conducted a ran-domized control study on 161 third-year medical students

who were randomly assigned into two groups: in-simulation debrief and postsimulation debrief. Learning ob-jectives, critical actions in the simulation, and type ofdebrief they would be assigned to were discussed prior tothe simulation. One scenario involved a patient with sinustachycardia elevation myocardial infarction who deterio-rated to ventricular fibrillation and the other a third-degree atria ventricular block who required cardiac pacing.The 84 students in the control group were provided imme-diate feedback during the simulationda ‘‘pause anddiscuss’’ experience. The experimental group, comprising77 students, were given comprehensive instructor-facilitated debriefing after the simulation. Results showedthat both groups showed significantly higher postsimulationmeans and then presimulation means, both in self-reportedknowledge and confidence on a Likert-scale survey. Thepostsimulation experimental group, however, reportedmore effective learning and a better understanding of thecorrect and incorrect actions. Overall, postsimulation

Table 3 Debrief Models

Model or Author-Identified PhasesNational League for Nursing Simulation Innovation ResourceCenter (Anderson, 2008)

Beginning/Introduction/OpeningMiddleClosing/Summary

The Mayo Clinic Model for Debriefing (Mayo Clinic, n.d.) ExperienceReflectionConceptualizationExperimentation

Plus-Delta (Decker et al., 2013, Jeffries, 2010) What went wellWhat would like to changeHow to change

Advocacy-Inquiry (Decker et al., 2013, Jeffries, 2010) Statement of observation followed by probing question of inquiry/whyLederman (1992) Systematic reflection and analysis

Intensification and personalizationGeneralization and application

GREAT (Owen & Follows, 2006) GuidelinesRecommendationsEventsAnalysisTransfer

Fanning and Gaba (2007) DescriptionAnalogy/analysisApplication

Dreifuerst (2010) EngageExplainElaborateEvaluateExtend

3D Model of Debriefing (Zigmont et al., 2011) DefusingDiscoveringDeepening

SHARP (Edgecombe et al., 2013) Set learning goalsHow did it goAddress concernsReview learning pointsPlan ahead future practice

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debriefing was more effective than the debriefing thatoccurred during simulation (p ¼ .001), suggesting thatpostsimulation debrief was more effective (Levett-Jones& Lapkin, 2012).

Cantrell (2008), in a focus group study of nursing stu-dents (n ¼ 11) who participated in teacher-facilitateddebrief immediately following the first two simulationsand with video-assisted debrief following the third, re-ported that they preferred to participate in debriefing imme-diately following simulation because the activity was freshin their memory, and they felt the method of debrief wasless important than the timing (Dufrene & Young, 2014).Similarly, Bond et al. (2004) in their study of emergencymedicine residents (n ¼ 15) found one of the themes thatemerged was that feedback was seen as more desirablefollowing the simulation experience (Dufrene & Young,2014).

Environment in Which the Debrief Takes Place

There is significant evidence that experiential learningcauses feelings of anxiety in the learner and as such itremains important to create a safe environment forparticipant debrief (Decker et al., 2013). Furthermore,Decker et al. (2013) suggest that it is made clear that thereis an expectation of confidentiality in regards to the simu-lation scenarios, the participant’s actions, and debrief dis-cussions. Rules of conduct must also be clear concerningconstructive, honest, and respectful feedback. Sufficienttime needs to be allocated in the early phase of reactionin debrief to elicit emotional and cultural responses(Chung, Dieckmann, & Saul, 2013), and personal re-sponses and experiential reflections should be explored(Dreifuerst, 2012). There is a need for both participantsand observers to be active in the debrief process (Deckeret al., 2013). Gardner (2013, p. 170) supports the impor-tance of the environment and the reassurance that debrief-ing is confidentialda ‘‘zone of safety.’’ The need forconfidentiality was elaborated on by Rudolph et al.(2013), who contends that a safe environment is neededto discuss openly and honestly. This can be addressed bystating upfront that simulation can be confusing and devel-oping a contract with rules for engagement and confiden-tiality (Dreifuerst, 2012). Pivec (2011) also suggestedthat confidentiality remains paramount and may well beestablished by a confidentiality agreement, and the debriefenvironment should be separate from the simulation wherepossible.

The Person Who Should Facilitate the Debrief

The International Nursing Association for Clinical Simu-lation and Learning, in their best practice guidelines fordebriefing (2011), states that the simulation debrief shouldbe done by the person who observes the clinical experience

with the aim of closing the gap between desired and actualperformance (Decker et al., 2013; Edgecombe et al., 2013).The standard practice in simulation is for educators toobserve the simulation and the same educators to debrief:observing guides the facilitator on how to review actions,decisions, and judgments of the participants (Dufrene &Young, 2014; Lusk, 2013).

Training of the Debrief Facilitator

Debriefing facilitators require skill in diagnosing thelearning needs of participants and the ability to adjust thelevel of facilitation needed for the group. They should haveformal training and assessment (Decker et al., 2013). Com-petency should be validated through input from learners,those experienced in debrief and assessment instruments.The facilitator also needs to practice in simulated environ-ments (Decker et al., 2013).

Rall, Manser, and Howard (2000) found in a study of 14participants that debriefing is essential to successfullearning, and poorly performed debriefing can result inmisinformation, bad habits, humiliation, and decreasedinvolvement and motivation in participants (as cited inPivec, 2011). Gardner (2013) suggests that skills for de-briefing should be refined through ongoing educational ac-tivities, peer assessments, and self-education. Educatorsneed to understand the debriefing process (Dufrene &Young, 2014; Gardner, 2013).

Identification of Learning Outcomes

Debriefing should be based on the preset learning outcomesof the simulation experience (Decker et al., 2013). Theseset the expectations for the debrief and define the standardof performance expected of the learner (Rudolph, Simon,Raemer, & Eppich, 2008). This is supported by the ImperialCollege London Handbook for debriefing (2013). Thishandbook outlines basic principles for high-quality debriefbased on a comprehensive literature review and an interna-tional interview study of debriefing experts using theirSHARP tool. It recommends setting learning objectivesbefore the simulation and reviewing these learning out-comes during debrief: ‘‘Learning objectives are imperativeto enable the student to build their knowledge base and pro-vide a more focused and deeper learning experience thatpromotes critical thinking and clinical reasoning’’(Edgecombe et al., 2013, p. 12).

In a study conducted on 68 junior nursing studentsexperiencing a 20-minute simulation with high-fidelitymannequins, self-confidence and satisfaction with simula-tion experience were assessed using a student’s satisfactionand self-confidence in learning five-point Likert scale. Theresults clearly indicated the need for clear objectives andincreased learning when these objectives could be linked totheir actions in debrief (Smith & Roehrs, 2009).

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Method of Debrief

There are many different debrief models; however, thescarce amount of research into this area does not allow forthe establishment of best model. What is clear is thatdebriefing should be based on a structured framework; itshould allow learner to progress through the identifiedphases of debrief: reaction, analysis, and summary or othersimilar phases and frames identified (Decker et al., 2013;Mariani et al., 2013).

Fanning and Gaba (2007) suggest that debriefing followsa constructivist teaching strategy focusing on what wasdone correctly and what would they do differently evokingdeductive and inductive thinking (Rudolph et al., 2008). Itinvolves a description of the events including reactions,analogy or analysis of students’ perspectives, assumptionsand goals, and application to future learning (Gardner,2013).

Similarly, Advocacy-Inquiry (Decker et al., 2013;Jeffries, 2010) begins with an observation or inquiry andagain utilizes a constructivist model to explore participant’sactions assumptions and understandings to determine appli-cation and critical thinking.

Plus Delta (Decker et al., 2013; Jeffries, 2010) requiresthat the debrief explores what went well? (Plus column),what did not go well? (Delta column), and how to change?This technique benefits debrief that has only a short amountof time available for delivery and aims to explore how sys-tems function rather than frames (Levine, DeMaria,Andrew, & Sim, 2013). When combined with Advocacy-Inquiry, it lends well to team and individual learning.

Dreifuerst (2012) found that structured debriefing formeaningful learning (DML) had a positive influence onthe development of clinical reasoning skills in undergradu-ate nurses. It guided the student through clinical reflectionusing a structured process of engage, evaluate, explore,explain, elaborate, and extend. This study involved 238nursing students who were allocated either to the controlgroup using customary debrief structure or to an experi-mental group using DML. Results were compared usingthe Health Sciences Reasoning Test. Statistically significanthigher scores were found posttest on those in the experi-mental group using DML (Mariani et al., 2013). Marianiet al. (2013) conducted a mixed method study on 86 juniorlevel nursing students who were assigned to either a controlgroup experiencing standard debriefing postsimulation orthe experimental group who received DML debriefing post-simulation. The students were assessed on four componentsof clinical judgment: noticing, interpreting, responding, andreflecting using the Lasater Clinical Judgment Rubric thathas interrater reliability of 0.97. In this study, no statisticaldifference was found. A focus group comprising of 60-minute interviews found that all students from both groupsreported debriefing regardless of type assisted them withtheir learning.

The SHARP tool was established by the ImperialCollege of London (2012) to provide a pneumonic toensure that debriefers covered the basics in debrief, deter-mined after reviewing the literature and employing a qual-itative study of (n ¼ 33) semi-structured interviews withsurgeons, anesthesiologists, and operating room nursesfrom the United Kingdom, United States, and Australia.SHARP tool involves: setting the learning goal, how didit go, addressing the concerns, reviewing learning points,and planning ahead for future practice.

Similarly, GREAT (Owen & Follows, 2006) utilizes apneumonic to ensure the basics of debrief are adhered toGuidelines that ensure the facilitator has followedevidence-based practice, and if these are not available thefacilitator has used the best Recommendations from pub-lished reviews. Events involve ensuring participants haveadequate time to reflect, Analysis, and the Transfer knowl-edge (Owen & Follows, 2006).

The 3D model (2011) explores reactions to the experi-ence, analysis of behavior, and synthesis of knowledge byDefusing emotions and reactions, Discovering possiblealternative responses, and Deepening by connecting tonew learning (Zigmont, Kappus, & Sudikoff, 2011).

Lederman (1992) identified seven elements of the de-briefing experience: the debriefer, the participants, the expe-rience, the impact of the experience, the recollections andreporting of the experience, and the time to process it. Allare addressed during the three phases of reflection and anal-ysis, intensification and personalization, and generalizationand application, exploring the experience, the meanings forthem, and broadening these to other experiences.

The Anderson (2008) model of debriefing was adoptedby the National League of Nursing for their SimulationInnovation Resource Center. It simplifies the process toensure there is a beginning or introduction, middle, andclosing or summary. It offers the ability to integrate severalother models into this structure to allow for more guidance.

The last model identified is the Mayo Clinic model ofdebriefing that is based on the Kolb Learning style (2005)and leads the student through experience, reflection,conceptualization, and experimentation (Pivec, 2011).

A synopsis of the different debriefing models identifiedduring the integrative review can be found in Table 3.

Discussion

Taking into account the review of the literature, a clinicalbottom line is established to determine best practiceguidelines. Findings included the following:

� Debriefing is the most important component for devel-oping clinical judgment in simulation-based learning(Kelly, Hager, & Gallagher, 2014). Debriefing is themost important component in knowledge acquisition

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in simulation-based learning, resulting in significant in-creases in knowledge (Dufrene & Young, 2014). De-briefing after simulation-based learning for healthcare students leads to a significant increase in the con-fidence to care for the unstable patient (Buckley et al.,2012; Dufrene & Young, 2014).Best practice: Debriefing is an essential component ofsimulation-based learning� Facilitator-only debriefing is as effective as facilitator-and video-assisted debriefing in achieving learning out-comes (Levett-Jones & Lapkin, 2012, 2014; Lorelloet al., 2014; Reed et al., 2013).Best practice: Facilitator-only debriefing and video-assisted debriefing can both be used as effective tech-niques in debriefing.� Debriefing is more effective when it immediately fol-lows the simulated clinical experience in terms ofknowledge and confidence (Dufrene & Young, 2014;Levett-Jones & Lapkin, 2012).Best practice: Debriefing immediately follows thesimulation-based learning activity.� There is a need to create a safe environment and confi-dentiality for debriefing to be effective in simulation-based learning (Decker et al., 2013; Dreifuerst, 2012).Best practice: A confidential safe environment is createdto ensure that debriefing is effective for the learner.� The debrief facilitator should be formally trained in de-briefing (Decker et al., 2013; Dufrene & Young, 2014).

� The debrief facilitator’s competency should be assessedthrough input from learners, practice in simulate envi-ronments, and assessment instruments (Decker et al.,2013; Gardner, 2013).Best practice: The debrief facilitator receives formaltraining, feedback, assessment, and ongoing experienceto ensure competency.� The person who observes the simulation should be theperson who facilitates the debrief (Decker et al., 2013;Dufrene & Young, 2014; Edgecombe et al., 2013).Best practice: The debriefing is facilitated by the personwho observed the simulation-based activity.� Debriefing should be based on the preset learning out-comes (Decker et al., 2013; Rudolph et al., 2008,2013).Best practice: Debriefing is based on the preset learningoutcomes.� Debriefing should be based on a structured framework;however, researchers differ about which framework ismost effective (Decker et al., 2013; Dreifuerst, 2012;Gardner, 2013; Mariani et al., 2013).Best practice: Debriefing uses a structured framework.

Conclusion

There is no denying that simulation-based learning con-tributes to the development of much desired abilities of

critical thinking and clinical reasoning for proficient healthpractitioners. The debrief phase of the simulation tradition-ally follows the main simulation exercise and is arguablythe most important component of the activity. Following anextensive literature review, it was established that there areeight best practice recommendations to facilitate thedebrief process. It was further found that althoughsimulation-based learning creates a safe environment todevelop clinical psychomotor skills and knowledge, dedi-cated research on the debriefing phase remains scant andfurther research is needed. Findings from this integrativereview strongly suggested that a safe, structured debrieffollowing the simulation immersion is aligned to bestpractice. Best practice in simulation is conducive topromote clinical psychomotor skills and knowledge.

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International Journal of Medical Education. 2015;6:118-120 Perspectives ISSN: 2042-6372 DOI: 10.5116/ijme.55fb.3d3a

118 © 2015 Claire L Burns. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of work provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0

Using debriefing and feedback in simulation to improve participant performance: an educator’s perspective Claire L Burns

Department of Medical Education, Royal Bolton NHS FT, Bolton, UK

Correspondence: Claire L Burns, Department of Medical Education, Royal Bolton NHS FT,Minerva Rd, Bolton, BL4 0JR, UK. Email: Claire.Burns@boltonft.nhs.uk

Accepted: September 17, 2015

Background

As a clinical skills educator I am involved in the delivery of simulation based education for UK trained doctors in their first year post qualifying (Foundation Year 1 [FY1]). I have an interest in the use of feedback and debrief as a tool to improve performance through reflection.

When relating simulation to Kolb’s1 learning cycle it is evident that taking part in the simulated scenario only accounts for the concrete experience component. Debrief and feedback accounts for the reflective observation, abstract conceptualization and active experimentation components of the learning cycle by helping participants make sense of the simulation scenario and reflect on their practice to improve future performance.

Preparation for simulation A simulation event took place in a hospital skills laboratory set up to resemble a patient bed space. All simulation scenarios involved the management of an acutely unwell patient. Each participant was an FY1 doctor and all partici-pated in a simulation scenario followed by feedback from both faculty and the other participants attending the event.

Four participants attended the event in total. This small group size allowed for debate and discussion as well as helping students to feel relaxed and promoting interaction between the participants. All participants had completed their training in the UK so it was assumed they already had a threshold of knowledge and skills as documented by the General Medical Council (GMC).2

Prior to the simulation event individualized scenarios were developed relevant to each participant’s current placement as it is important for the simulation to be appro-priate for students’ needs.3, 4 It could be argued that by only focusing on what it is felt students “need to know” they are not experiencing a full breadth of learning. However, I consider that the scenarios delivered to the students are common emergency scenarios that could potentially be experienced across all disciplines of medicine.

Learning outcomes that fulfilled the requirements of the GMC5, 6 were used as a basis for developing the simulations. Clear outcomes were set for the event so participants knew what knowledge; skills, attitudes and behaviours needed to be demonstrated.3,8 The outcomes included both the tech-nical and non-technical aspects of care delivery. Both of these aspects are imperative in delivering safe patient care 5-9

and are focused on critical thinking and problem solving. Discussing the learning outcomes at the beginning of the event enabled exploration of the importance of non-technical skills. In the future, I plan to ask the students what their objectives for the session are to increase participation, motivation and performance.10 The HEA11 recognizes that student centred learning increases student confidence and excitement about the subject.

Delivering the simulation On the day of the simulation, students were given an overview of each of the faculty members’ roles and infor-mation regarding the manikin’s limitations and equipment being used. Identifying limitations before starting the scenarios improved fidelity3 as the faculty didn’t have to interrupt the scenario to acknowledge constraints.

Providing a pre-brief at the beginning of the session was useful and helped to facilitate reflective practice by prepar-ing students for the discussion at the end of their scenario and making them aware of how they would receive their feedback.12 It also alerted the students that they were equal partners in the feedback process and triggered internal feedback.12, 13

Each student was allocated a scenario and acted as the team leader whilst faculty acted as other members of the healthcare team. During the scenario the faculty observed the students’ so that feedback could be given. Howev-er,direct observation does not facilitate in-depth exploration of clinical reasoning or problem-solving abilities.14 In future sessions a member of the faculty will act as a medical

Int J Med Educ. 2015; 6:118-120 119

student to question the participant and determine their underpinning knowledge.

Debrief and feedback After completing the individual scenarios, oral feedback was given to students by the faculty and their peers. Group feedback and peer learning are all effective assessment for learning tools.11 Individuals can learn a lot through the experience alone but specific feedback will maximise learning.15, 16

Waiting until completion of the scenario before giving feedback allowed the participants to self-reflect and make sense of what had just happened. Facilitators and peers were then able to discuss the strengths and weaknesses of the student’s performance without interrupting the scenario and decreasing scenario fidelity and allows participants to discuss the consequences of their actions.15

Feedback on the participant’s performance is the most important feature of simulation education as it produces long lasting learning and allows the student to develop a deep insight and reflection about their performance as well as slowing the decay in knowledge.3

During debrief students discussed any emotions that they had about the simulation scenario as well as reflecting on and exploring their decision making processes. Giving oral feedback to students enabled the faculty to be flexible with their questioning, allowed an immediate response from the student and permitted clarification of any misunder-standings.17 However, oral feedback does not allow the person giving feedback time to reflect on the student’s performance.18

A criticism from one of the participants was that they would have liked written feedback for portfolio evidence. One option would be for the faculty to meet after the event, discuss each student’s performance and then email individ-ual feedback. However, this option would be time consum-ing and may not be feasible.

When giving feedback, the first question the student was asked was: “How do you feel that went?” This facilitated self-evaluation which is essential to reducing the emotive impact of feedback.13 Facilitating self-evaluation will also promote the student to function in a reflective mode in their daily practice. However, we all hold biases in the way we judge our own performance.13 Self-evaluation relies on the student to be self-aware and effective at critiquing their own performance;13 a skill not always present. Self-evaluation alone is inadequate for performance improvement,19 it needs to be facilitated by skilled evaluators who can change their questioning strategy appropriately to ensure student understanding.17

Overall participants evaluated the simulation event as a valuable learning experience that gave them a chance to apply their theoretical knowledge to simulated reality and made them aware of the national and local guidance availa-ble to them. However, feedback was identified as an area for

faculty development. One student asked for “more strict feedback” This feedback itself is somewhat unhelpful due to its vagueness. Another student asked that the “feedback sandwich” be “more strictly enforced”. I have never been a devotee to the feedback sandwich as I find it predictable, patronising and a wasted opportunity to discuss the meat of the issue and improve student performance. For feedback to be useful it needs to lead to action which will improve the student’s performance.1,13,16,19 Feedback can only do this if it identifies specific areas for development and supports the learner in identifying strategies to bridge the gap between current and desired performance.5, 16

The simulation event presented valuable learning for the faculty. Most student errors were human factor errors. For example, guidelines were either not used or not followed correctly and communication was often poor leading to delays in patient treatment. In future sessions more empha-sis will be put on human factor training and a structured model of debrief will be used.

Conflict of Interest

The author declares that she has no conflict of interest.

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